Sign Off Clinical Documentation

Insight EMR is designed to properly aggregate procedure codes based upon the clinical services documented by the clinician. Clinical services are associated with the proper procedure code. Procedure codes and units are aggregated based upon procedure code definitions and any special billing rules for the patient's insurance.

At sign off, the system compares the number of minutes scheduled to the patient's actual visit time. By default, the patient time in and time out is set to the appointment start and end time. As illustrated below, the therapist can adjust the minutes for each procedure, each CPT code or the patient time in and time out in order to ensure that the documented time is not more or less than the visit time.

If this is not done, and the minutes documented in the chart note exceeds the visit time (the visit end time minus the visit start time) by more than the minutes established in your overbilling policy (Clinicient recommends that you allow no overbilling by setting the offset to one minute), an overbilling alert is created indicating a potential compliance issue.

If the number of minutes documented is less than the visit time and the amount exceeds the offset (Clinicient recommends five minutes), an under-billing alert is created indicating potential loss of billable time. Also if a visit is signed with no charges, an under-billing alert is created. There are legitimate reasons why a therapist may under-bill and there may be legitimate reasons for overbilling, but it is best to review the alerts to ensure compliance and to maximize revenue.

Note: The alerts are based on the minutes documented, not the minutes billed. It is possible that time will be documented but not billed due to billing rules in place for the payer. Any code that is not billed will appear on the Trimmed Procedures report, which is found on the Reports tab in the Management reports category.

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